What are the emergency management guidelines for renal colic?

Emergency Management of Renal Colic

NSAIDs are the first-line treatment for renal colic pain management, with diclofenac 75mg intramuscularly being the most effective option for immediate pain relief. 1

Diagnosis and Assessment

Clinical Presentation

• Abrupt onset of severe unilateral flank pain radiating into groin or genitals
• Examination should establish site of maximal tenderness
• Vital signs assessment to exclude shock and systemic infection 1

Diagnostic Testing

• Urinalysis should be performed immediately
  • Hematuria supports diagnosis (present in >80% of cases)
  • Consider alternative diagnoses if urinalysis is negative 1

Red Flags Requiring Immediate Hospital Referral

• Shock
• Fever
• Oligoanuria
• Age over 60 years
• Delayed menses in women 1

Treatment Algorithm

First-Line Pain Management

• NSAIDs are strongly recommended as first-line treatment with high-quality evidence showing they are more effective than opioids 1
• Benefits of NSAIDs over opioids include:
  • Less need for rescue analgesia
  • Lower rates of vomiting
  • More sustained pain relief 1

Preferred NSAID Options (in order of preference):

1. Diclofenac 75mg intramuscularly (most effective route) 1, 2

   • For moderate pain: Oral diclofenac 50mg initially, followed by 50mg every 8 hours as needed 1

2. Ibuprofen intravenously (alternative option)

   • Research shows IV ibuprofen is more effective than IV paracetamol for renal colic pain relief 3
   • In one study, IV ibuprofen provided significantly better pain reduction at both 15 and 30 minutes compared to paracetamol 3

3. Ketorolac intravenously (alternative option)

   • Comparable efficacy to diclofenac in some studies 4
   • May be less effective than ibuprofen in certain formulations 1

Second-Line Pain Management

• Opioids with an antiemetic when NSAIDs are contraindicated 1

  • Avoid pethidine due to higher rates of vomiting
  • Preferred options: oxycodone, hydromorphone, or fentanyl (especially for patients with kidney disease) 1

• Drotaverine 80mg intramuscularly as an alternative when NSAIDs are contraindicated

  • Reported efficacy comparable to diclofenac 1

Contraindications to NSAIDs

• Severe renal impairment
• Heart failure
• Pregnancy (especially after 30 weeks gestation)
• History of peptic ulcer disease
• Cardiovascular disease
• Concurrent use of ACE inhibitors, ARBs, or diuretics 1

Patient Management

Immediate Care Instructions

• Maintain high fluid intake
• Strain urine to catch any passed calculi 1
• Reassess pain 1 hour after initial treatment 1

Follow-up Care

• Fast-track investigation should be initiated within 7 days of symptom onset
• Arrange urgent urology outpatient appointment within 7-14 days if renal imaging shows a problem requiring intervention 1

Clinical Pearls and Pitfalls

Important Considerations

• A network meta-analysis found that diclofenac via IM route is recommended for patients without risks of cardiovascular events 5
• Combination therapy (NSAIDs plus other agents) may be considered for uncontrolled pain after initial NSAID administration 5
• While combination of NSAIDs and antispasmodics is sometimes used, evidence suggests it is not superior to NSAIDs alone for pain control 6

Common Pitfalls to Avoid

• Using opioids as first-line treatment: Evidence clearly shows NSAIDs are more effective with fewer side effects 1, 2, 6
• Failing to reassess pain after initial treatment
• Neglecting to arrange appropriate follow-up for patients with confirmed stones
• Using NSAIDs in patients with contraindications 1

Long-term Management

• Increased fluid intake
• Preventive strategies such as thiazides, citrates, or allopurinol for recurrent stones
• Potassium citrate for uric acid and cystine stones 1
• For patients with recurrent stones, obtain 24-hour urine collection within six months of treatment initiation 1